Surgery remains the only curative option for hypospadias. Despite advances in surgical techniques, the treatment of proximal hypospadias continues to face challenges, including a high complication rate, difficulties in meeting functional requirements, and poor cosmetic satisfaction [5]. Previous studies underestimated the actual complication rates of this subtype due to limited follow-up periods and incomplete evaluation methods. Recent evidence indicates that the complication rate for proximal hypospadias approaches 50% [6], especially involving the glans penis. Firstly, hypoplastic glans lacks proper frenulum and coronal sulcus structures, and its tissues are fragile. High tension often arises when suturing bilateral glanular wings. Additionally, the blood supply of the glans relies mainly on branching vessels, collectively increasing the risk of poor postoperative healing. Secondly, even with postoperative catheterization, urine leakage is difficult to fully prevent, which raises the risk of local contamination and infection. Finally, the glans is prone to mechanical stimuli, such as stretching, friction, and pressure, further elevating the potential for postoperative complications. Due to the high complication rate involving the glans, some surgeons reconstruct the urethra only up to the coronal sulcus, avoiding glanular urethral reconstruction in severe cases [7]. However, achieving a normal glans appearance with a slit-like meatus positioned correctly is crucial for surgical success. Therefore, optimizing glanular surgical techniques has significant clinical value.

Current surgical optimization strategies for hypoplastic glans primarily involve tension control and tissue reinforcement via local mobilization. White et al. proposed a deep glandular wing incision method to reduce tension by dissecting the glanular wings deeply to achieve tension-free closure [8]; however, this method does not address the issue of small glans volume. Partial glanular reduction techniques can reduce tension and enlarge the urethral opening to minimize complications, but they further reduce tissue volume, causing potential loss of cavernous tissue and reduced sensitivity [9]. LYU Y Q et al. [10]introduced a novel technique using dysplastic corpus spongiosum and Buck’s fascia to increase tissue volume and provide coverage during glanuloplasty. Although this method reduces urethral fistula and glanular dehiscence while enlarging the glans, it increases the risk of urethral diverticulum formation. Furthermore, the epidermal, vascular, and nerve receptor distributions in the glans differ significantly from penile shaft tissues. [11] Transferring external tissues to the glans may adversely affect structural and functional integrity and compromise cosmetic outcomes. This study addressed the limitations of traditional high-tension suturing and insufficient glanular volume. The modified glanuloplasty technique reduces tension to enhance healing, decreases complications, and utilizes glanular tissue proliferation for expansion.

Healing capacity closely correlates with postoperative recovery in hypospadias, and tension significantly influences wound healing. Increased tension initially results in stretching or elongation of the extracellular matrix and cells, causing tissue stiffening. [12] Additionally, tension can induce chronic inflammation through local and systemic immune responses, promoting keloid formation and hypertrophic tissue proliferation [13]. Tension is a primary trigger for these pathological changes. In this study, local tissue tension was directly reduced through glanular wing incision, and urethral meatus repositioning increased the perimeter of the lateral wings to further alleviate tension. Moreover, expansion techniques enhanced the urethral accommodation space, partly by creating a dome-shaped cavity through urethral meatus relocation, directly enlarging glanular volume. Further expansion occurred via proliferative healing at the dorsal tension-relief site. Ultimately, this optimized surgical method reduces anastomotic tension, promotes wound healing, minimizes postoperative complications, enlarges the hypoplastic glans, and enhances cosmetic satisfaction.

Comparison of complications between the decompression-expansion group and conventional group revealed that the incidence of glanular dehiscence was significantly lower in the decompression-expansion group (0 cases vs. 4 cases; P < 0.05). Snodgrass et al. reported that glanular dehiscence was the most common indication for secondary surgery due to poor cosmetic outcomes and spraying urine streams. According to a 2022 meta-analysis by Karabulut et al. [14], proximal hypospadias, crippled penis, glanular width less than 15 mm, and urethral plate width less than 8 mm are associated with increased glanular dehiscence. This study demonstrated that glanular decompression and expansion effectively reduced glanular dehiscence in patients with proximal hypospadias and hypoplastic glans penis.

Urethral fistula is the most common complication after hypospadias surgery [15]. In the decompression-expansion group, 3 cases occurred, similar to the conventional group, and all located at the coronal sulcus. Studies indicate anatomical differences between the glans and penile shaft. The coronal sulcus represents a transitional region, characterized by a smaller circumference and thinner tissues, increasing the risk of poor healing. Thus, the decompression-expansion technique in this study has limited effectiveness in reducing tension at the coronal sulcus. To address this limitation, further surgical improvements will be implemented in future studies. One patient in the decompression-expansion group developed a urethral diverticulum, which healed successfully following surgical repair. Retrospective analysis identified improper urethral plate reconstruction width as the probable cause. Based on this finding, the surgical protocol has been optimized with precise quantification and strict control of urethral diameter, and no similar complications have subsequently occurred.

In terms of postoperative complication management, all cases were appropriately treated based on the type of complication. Urethrocutaneous fistulas and urethral diverticulum were successfully repaired through secondary surgical intervention, while urethral strictures were managed with regular urethral dilatation. These management strategies led to favorable recovery outcomes in the affected patients.

Glanular expansion involves two phases. First, direct expansion through enlargement of the glanular wings. Second, expansion via cellular proliferation, migration, and creeping growth. Wound healing is a dynamic, multi-stage process involving coagulation, inflammation, proliferation, and remodeling. [16] During the proliferation stage, fibroblasts actively produce collagen and elastic fibers, forming granulation tissue together with capillaries and endothelial cells to fill the wound space. No significant difference existed in preoperative glanular width between groups; however, after one-year follow-up, the glanular width in the decompression-expansion group was significantly greater (P < 0.05), demonstrating its advantage for hypoplastic glans reconstruction. The PPPS scale [17], used for postoperative hypospadias appearance assessment, showed increased satisfaction among family members and physicians regarding glanular shape, position, and shape of the urethral meatus, as well as physicians’ overall cosmetic satisfaction after decompression-expansion surgery.

In summary, glanular decompression and expansion surgery demonstrated advantages in reducing complications, improving anatomical reconstruction, and cosmetic outcomes. Key surgical considerations include: (1) incisions should allow tension-free coverage of the urethra by the glanular wings; (2) dorsal incision should be placed at the 12 o’clock position. The dorsal penile artery primarily nourishes the glans and distributes between the 8–10 and 2–4 o’clock positions, with terminal branches entering vertically into the glans, resulting in minimal bleeding post-incision; (3) the apex of the reconstructed urethral meatus should be positioned at the highest point of the glans after tension release, and its lowest point 3 mm proximal to the coronal sulcus; (4) epidermal suturing at the dorsal incision can be performed based on tension-release conditions; (5) all surgical manipulations should remain superficial to the tunica albuginea to minimize intraoperative bleeding, along with careful hemostatic management.

This study has certain limitations. First, the two groups of patients underwent surgery at non-simultaneous surgery periods, with the conventional group being treated earlier than the decompression and expansion surgery group. The lack of a contemporaneous control group may introduce bias due to the surgical learning curve, potentially overestimating the true efficacy of the modified technique. Second, although the decompression and expansion technique effectively reduced suture tension at the penis glans and significantly decreased the incidence of glans dehiscence, its ability to reduce tension at the coronal sulcus was limited. As a result, the technique showed limited impact in lowering the rates of urinary fistula and overall complications. Although the cosmetic evaluation using the PPPS core demonstrated notable improvements in satisfaction for certain some items in the modified surgery group, the improvement in overall PPPS scores remained limited. This suggests that while the technique may enhance specific aspects of penile appearance, its effect on comprehensive cosmetic perception may be modest. In addition, the study was constrained by a small sample size and relatively short follow-up period, which limits the ability to assess long-term complications and functional outcomes, including sexual function. Nevertheless, all procedures were performed by the same experienced pediatric surgeon, minimizing technical variability bias. In conclusion, glanular decompression and expansion surgery provides an alternative strategy for treating proximal hypospadias with hypoplastic glans, effectively addressing reconstruction challenges, reducing glanular dehiscence incidence, enhancing glanular size, and improving cosmetic satisfaction. Future studies should optimize surgical techniques, implement multicenter studies with larger sample sizes, and explore quantitative tension analysis and tissue engineering technologies.